Risk stratification to prevent SCD in young athletes presentation by Prof.Khaled Hussein, Critical Care Center, Cairo University

1. Risk Stratification to Prevent SCD
in Young Athletes
Dr /Khaled Hussein,MD
Professor at Critical Care Medicine department
Consultant Electrophysiologist
Cairo University
2019

2. Background
 Regular sports participation is encouraged by the medical
community as part of cardiovascular prevention measures,
because it improves fitness and reduces cardiovascular
morbidity and mortality worldwide.
 A large proportion of the young population participates in
competitive or recreational sports activity

3.  However, for a small number of individuals who harbor
cardiac conditions, exercise can sometimes be associated
with the risk of sudden death (i.e., the exercise paradox).
Sudden cardiac death (SCD) is the most frequent medical
cause of sudden death in athletes.

4. The definition of SCD in athletes
 Sudden cardiac death (SCD) is an unexpected death due to
cardiac causes that occurs in a short time period (generally
within 1 hour of symptom onset) in a person with known or
unknown cardiac disease.
 Some estimates of incidence include only deaths with
exertion or shortly (< 1 hour) after exertion.

5. Victims of SCD among Young Athletes
in Egypt

6. Risk Factors of SCD
Harmon KG, Drezner JA, Wilson MG, Sharma S. Br J Sports Med. 2014 Aug;48(15):1185–92
Meagan M. Wasfy, Adolph M. Hutter, and Rory B. Weiner. Methodist Debakey Cardiovasc. J 2016 Apr-Jun; 12(2): 76–80.

7. Causes of SCD
Hayashi et al, Circulation Research June 5, 2015

8. Identifiable causes of SCD in Athletes
Ackerman et al Sudden Cardiac Death in the Young
Circulation. 2016;133:1006-1026

9.  More comprehensive investigations in the United States and
international populations-athletes, non-athletes, and military-
support that the most common finding on autopsy in young
individuals with SCD is actually a structurally normal heart
(autopsy-negative sudden unexplained death)
Asif & Harmon .Sports Health. 2017 May/Jun;9(3):268-279.

10. Screening tools for CV evaluation
Wasfy et al. Methodist Debakey Cardiovasc J. 2016 Apr-Jun; 12(2): 76–80.

11. Twelve-lead ECG as a screening tool
what are the problems?
 Trained athletes commonly (up to 80%) show ECG changes such
as sinus bradycardia, first-degree atrioventricular (AV) block and
early repolarization, which result from physiological adaptation of
the cardiac autonomic nervous system to athletic conditioning, such
as increased vagal tone and/or withdrawal of sympathetic activity.
 Misinterpretation of benign physiological ECG changes is not
uncommon particularly when performed by physicians without
expertise in sports cardiology
Holly RG et al,1998

12. Twelve-lead ECG as a screening tool
what are the problems?- cont
 False-positive ECG findings can result in unnecessary, costly
secondary investigations and disqualification from sport.
 The high false-positive ECG rates and impact on specificity are
commonly cited as major limitations of the ECG as a screening test
in young athletes
 So, an ECG criteria development to improve the efficacy of ECG
screening to acceptable levels of false-positive rates and high rates
of sensitivity to identify athletes at risk of SCD is mandatory

13. Drezner JA etal, Br J Sports Med. January 10, 2013

14. Drezner JA etal, Br J Spots Med. 2016

15. International consensus Standard for
ECG interpretation in Athletes
Drezner JA, et al. Br J Sports Med 2017

16. Echocardiography as a screening test
 The use of echocardiography as a screening test is
controversial.
 Routine use of echocardiography is expensive.
 Echocardiography is not the best modality to detect patients
with arrhythmogenic abnormalities such as ion
channelopathies and Wolf-Parkinson-White syndrome that
lead to SCD

17.  Echocardiography is more useful in detecting HCM and
coronary artery anomalies, which are the most common
causes of SCD in the United States

18. Echo Res Pract. 2018 Mar; 5(1): G1–G10.

19. Upper limits for ventricular dimensions
in athletes
Echo Res Pract. 2018 Mar; 5(1): G1–G10.

20. Echo Res Pract. 2018 Mar; 5(1): G1–G10.

21. Echo Res Pract. 2018 Mar; 5(1): G1–G10.

22. Arrhythmia in Structurally normal heart
 Congenital Long QT syndrome
 Catecholaminergic polymorphic VT (CPVT)
 Brugada syndrome
 Other ion channelopathies

23. Pre-excitation syndrome
 Atrioventricular (AV) bypass tracts cause early, anomalous ventricular
activation before normal activation through the AV node
 Estimated prevalence 1:1,000
 Can be asymptomatic or present with paroxysmal supraventricular
tachycardia symptoms – palpitations, syncope
 Symptomatic patients at high risk of SCD (≈0.15%/yr)
 Ventricular pre-excitation seen in ≈1% of athletes with SCD
Hiss RG, Lamb LE. Circulation 1962;25:947–61
Maron BJ et al. Circulation 2009;119:1085–92

24. ECG diagnosis of pre-excitation

25. Management of asymptomatic pre-
excitation

27. Long QT syndrome
 Group of disorders characterised by prolonged QT interval on ECG and
predisposition to develop life-threatening arrhythmias such as torsades de
pointes during exercise or stress.
 Prevalence of 1:2,000 newborns.
 Disease-causing mutation can be identified in 75% of patients by genetic
screening.
 Emotional stress and exercise, particularly swimming, are important triggers
for ventricular arrhythmias and SCD in LQT1, but significant overlap exists
between genotypes.
Schwartz PJ et al. Circulation 2009;120;1761–7 2
Ackerman MJ et al. Europace 2011;13:1077–109

28. LQT syndrome: Diagnosis
 Measurement of QTc using Bazett's formula on repeated 12-lead
ECG at stable heart rates (60–100 bpm).
 Consider LQTS if unexplained syncope and QTc >460 ms or
asymptomatic and QTc ≥480 ms
 When QTc prolongation not obvious, use risk score (age,
clinical/family history, QTc duration, T-wave morphology, previous
history of torsade de pointes); LQTS risk score >3 is diagnostic
Priori SG et al. Europace 2015;17:1601–87 2.
Schwartz PJ et al. Circulation 1993;88:782–4

29. Genes involved in monogenic
causes of SCD
Alfred L, George JR .J Clin Invest. 2013 Jan 2; 123(1): 75–83.

30. Brugada syndrome
 Characterized by right bundle branch block, persistent ST
segment elevation and sudden death due to polymorphic
ventricular tachycardia(PVT) and/or VF in absence of other
cardiomyopathies
Brugada P, Brugada J. JACC 1992;20:1391–6
Type I Brugada

31. Brugada syndrome
 May be accompanied by mild RV abnormalities
 Inherited disease, but may be sporadic in up to 60% of cases
 Prevalence of 1:1,000 in Asia, but <1:10,000 in Europe and
America
 Ventricular arrhythmias generally occur at rest. Chronic
athletic
 conditioning or raised body temperature during exercise may
exacerbate the condition
Rudic B et al. Europace 2016;18:1411–9
Mizusawa Y, Wilde AA. Circ Arrhythm Electrophysiol 2012;5:606−16

32. CPVT
 It is an adrenergic-induced bidirectional or polymorphic ventricular
tachycardia
 Prevalence around 1:10,000
 Two-thirds of cases due to known genetic mutations, Silent mutations
in 20%
 If undiagnosed, mortality rates are 30–50% by age 40
 Physical activity is a common trigger of ventricular arrhythmias in
patients with CPVT
 Diagnosis – structurally normal heart, normal ECG. Effort or emotion
trigger ventricular premature beats that increase in complexity with
heart rate
Priori SG et al. Europace 2013;15:1389–406 2.
Priori SG et al. Circulation 2002;106:69–74

33. BDVT VVF

35. Management of affected athletes with
pry arrhythmia syndrome
 Genetic testing+ family screening
 Removal of the triggers
 Beta Blockers (BBs)
 Antiarrhythmic drugs ) AADs
 Intra-cardiac defibrillator (ICD)
 Lt cervical sympathectomy

36. ECG-1
 Incomplete RBBB
 QRS duration <120 ms
 Normal findings in athletes
 Does not require additional evaluation

37. ECG-2
 SB
 Early repolarization
 LVH voltage criteria
 Common training related findings
 Does not require more evaluation

38. ECG-3
 Deep T wave inversion
 ST depression in lateral leads
 Bi atrial enlargement
 Left axis deviation
 Needs further evaluation
 HCM

39. ECG-4
 Complete RBBB
 QRS duration >120 ms
 Left axis deviation
 RA enlargement
 Additional investigations are needed

40. ECG-5
 Complete LBBB
 QRS duration 120 ms
 Always abnormal findings
 Needs further evaluation

41. Take Home Message
 Sudden cardiac death in the athlete is a rare but catastrophic
event for families, teams, leagues, and communities.
 Prevention of SCD in young athletes remains the priority of
the sports medicine community.
 Early identification of individuals at risk through screening
may be an important complementary strategy to reduce the
overall burden of SCD in young athletes.

42.  With a better understanding of the physiological adaptations
in athletes and the electrical consequences of such
alterations, ECG criteria development to guide physicians
has significantly improved the efficacy of ECG screening to
acceptable levels of false-positive rates and high rates of
sensitivity to identify athletes at risk of SCD.

43. Thank you for attention